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lung cancer. What is cancer of the lung?. Disruption of the system of checks and balances on cell growth results in an uncontrolled division and proliferation of cells that eventually forms a mass known as a tumor. .

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what is cancer of the lung
What is cancer of the lung?
  • Disruption of the system of checks and balances on cell growth results in an uncontrolled division and proliferation of cells that eventually forms a mass known as a tumor.
slide24
. Malignant tumors, on the other hand, grow aggressively and invade other tissues of the body, allowing entry of tumor cells into the blood stream or lymphatic system which spread the tumor to other sites in the body. This process of spread is termed metastasis.
slide25
Since lung cancer tends to spread, or metastasize, very early in its course, it is a very life-threatening cancer and one of the most difficult cancers to treat. While lung cancer can spread to any organ in the body, certain organs – particularly the adrenal glands, liver, brain, and bone - are the most common sites for lung cancer metastasis.
slide27
Lung cancers can arise in any part of the lung. Ninety to 95% of cancers of the lung are thought to arise from the epithelial, or lining cells of the larger and smaller airways (bronchi and bronchioles); for this reason lung cancers are sometimes called bronchogenic carcinomas. Cancers can also arise from the pleura (the thin layer of tissue that surrounds the lungs), called mesotheliomas, or rarely from supporting tissues within the lungs, for example, blood vessels.
slide28
How common is lung cancer?Lung cancer is responsible for the most cancer deaths in both men and women throughout the world.
slide29
Lung cancer was not common prior to the 1930s but increased dramatically over the following decades as tobacco smoking increased. In many developing countries, the incidence of lung cancer is beginning to fall following public education about the dangers of cigarette smoking and effective smoking cessation programs. Nevertheless, lung cancer remains the most common form of cancer in men worldwide and the fifth most common form of cancer in women.
slide30
What causes lung cancer?SmokingThe incidence of lung cancer is strongly correlated with cigarette smoking, with about 90% of lung cancers arising as a result of tobacco use. The risk of lung cancer increases with the number of cigarettes smoked over time; doctors refer to this risk in terms of pack-years of smoking history (the number of packs of cigarettes smoked per day multiplied by the number of years smoke. While the risk of lung cancer is increased with even a 10 pack-year smoking history, those with 30 pack-year histories or more are considered to have the greatest risk for the development of lung cancer. Among those who smoke two or more packs of cigarettes per day, one in seven will die of lung cancer.
slide31
Pipe and cigar smoking can also cause lung cancer, although the risk is not as high as with cigarette smoking. While someone who smokes one pack of cigarettes per day has a risk for the development of lung cancer that is 25 times higher than a nonsmoker, pipe and cigar smokers have a risk of lung cancer that is about five times that of a nonsmoker.
slide32
Tobacco smoke contains over 4,000 chemical compounds, many of which have been shown to be cancer-causing, or carcinogenic. The two primary carcinogens in tobacco smoke are chemicals known as nitrosamines and polycyclic aromatic hydrocarbons. The risk of developing lung cancer decreases each year following smoking cessation as normal cells grow and replace damaged cells in the lung. In former smokers, the risk of developing lung cancer begins to approach that of a nonsmoker about 15 years after cessation of smoking.
slide33
Passive smokingPassive smoking, or the inhalation of tobacco smoke from other smokers sharing living or working quarters, is also an established risk factor for the development of lung cancer. Research has shown that non-smokers who reside with a smoker have a 24% increase in risk for developing lung cancer when compared with other non-smokers. An estimated 3,000 lung cancer deaths occur each year in the U.S. that are attributable to passive smoking.
slide34
What are the signs and symptoms of lung cancer?Symptoms of lung cancer are varied dependent upon where and how wide-spread the tumor is. A person with lung cancer may have the following kinds of symptoms:
slide35
No symptoms - In up to 25% of people who get lung cancer, the cancer is first discovered on a routinechest x-ray or CT scan as a solitarysmall mass sometimes called a coinlesion. These patients with small single masses often report no symptoms of lung cancer at the time it is discovered.
slide36
Symptoms related to the cancer – The growth of the cancer and invasion of lung tissues and surroundings may interfere with breathing, leading to symptoms such as cough, shortness of breath, wheezing, chest pain, and coughing up blood (hemoptysis). If the cancer has invaded nerves, for example, it may cause shoulder pain that travels down the outside of the arm (called Pancoast’s Syndrome)
slide37
or paralysis of the vocal cords leading tohoarseness. Invasion of the esophagus may lead to difficulty swallowing (dysphagia). If a large airway is obstructed, collapse of a portion of the lung may occur and cause infections (abscesses, pneumonia) in the obstructed area.
slide38
Symptoms related to metastasis – Lung cancer that has spread to the bones may produce excruciating pain at the sites of bone involvement. Cancer that has spread to the brain may cause a number of neurologic symptoms that may include blurred vision, headaches, seizures, or symptoms of stroke such as weakness or loss of sensation in parts of the body.
slide39
Paraneoplastic symptoms - Lung cancers frequently are accompanied by so-called paraneoplastic syndromes that result from production of hormone-like substances by the tumor cells. Paraneoplastic syndromes occur most commonly with SCLC but may be seen with any tumor type.
slide40
A common paraneoplastic syndrome associated with SCLC is the production of a hormone called adrenocorticotrophic hormone (ACTH) by the cancer cells, leading to oversecretion of the hormone cortisol by the adrenal glands (Cushing’s Syndrome). The most frequent paraneoplastic syndrome seen with NSCLC is the production of a substance similar to parathyroid hormone, resulting in elevated levels of calcium in the bloodstream.
slide41
Nonspecific symptoms - Non-specific symptoms seen with many cancers including lung cancers include weight loss, weakness, and fatigue. Psychological symptoms such as depression and mood changes are also common.
slide42
How is lung cancer diagnosed?Doctors use a wide range of diagnostic procedures and tests to diagnose lung cancer. These include:
slide43
The history and physical examination may reveal the presence of symptoms or signs that are suspicious for lung cancer. In addition to asking about symptoms and risk factors for cancer development, doctors may detect signs of breathing difficulties, airway obstruction, or infections in the lungs.
slide44
Cyanosis, a bluish color of the skin and the mucous membranes due to insufficient oxygen in the blood, suggests compromised function of the lung. Likewise, changes in the tissue of the nail beds, known as clubbing, may also indicate lung disease.
slide45
The chest x-ray is the most common first diagnostic step when any new symptoms of lung cancer are present. Chest x-rays may reveal suspicious areas in the lungs but are unable to determine if these areas are cancerous. In particular, calcified nodules in the lungs or benign tumors called hamartomas may be identified on a chest x-ray and simulate lung cancer.
slide46
CT (computerized axial tomography scan, or CAT scan) scans may be performed on the chest, abdomen, and/or brain to examine for both metastatic and primary tumor. A CT scan of the chest may be ordered when x-rays are negative or do not yield sufficient information about the extent or location of a tumor
slide47
The advantage of CT scans is that they are more sensitive than standard chest x-rays in the detection of lung nodules
  • Sometimes intravenous contrast material is given prior to the procedure to help delineate the organs and their positions
  • A CT scan exposes the patient to a minimal amount of radiation.
slide48
helical CT scan (or spiral CT scan) is sometimes used in screening for lung cancers. This procedure requires a special type of CAT scanner. The heightened sensitivity of this method is actually one of the sources of its drawbacks, since lung nodules requiring further evaluation will be seen in approximately 20% of people with this technique. Ninety percent of the nodules identified by low-dose helical screening CTs are not cancerous, but require up to two years of costly and often uncomfortable follow-up and testing.
slide49
(MRI) scans may be indicated when precise detail about a tumor’s location is required.. There are no known side effects of MRI scanning, and there is no exposure to radiation. The image and resolution produced by MRI is quite detailed and can detect tiny changes of structures within the body. People with heart pacemakers, metal implants, artificial heart valves, and other surgically implanted structures cannot be scanned with an MRI because of the risk that the magnet may move the metal parts of these structures.
slide50
Positron emission tomography (PET) scanning is a specialized imaging technique that uses short-lived radioactive substances to produce three-dimensional colored images of those substances functioning within the body. While CT scans and MRI scans look at anatomical structures, PET scans measure metabolic activity and functioning of tissue. PET scans can determine whether a tumor tissue is actively growing and can aid in determining the type of cells within a particular tumor.
slide51
Bone scans are used to create images of bones on a computer screen or on film. Doctors may order a bone scan to determine whether a lung cancer has metastasized to the bones. In a bone scan, a small amount of radioactive material is injected into the bloodstream and collects in the bones, especially in abnormal areas such as those involved by metastatic tumors. The radioactive material is detected by a scanner, and the image of the bones is recorded on a special film for permanent viewing.
slide52
Sputum cytology - The diagnosis of lung cancer always requires confirmation of malignant cells by a pathologist, even when symptoms and x-ray studies are suspicious for lung cancer. The simplest method to establish the diagnosis is the examination of sputum under a microscope.
slide53
If a tumor is centrally located and has invaded the airways, this procedure, known as a sputum cytology examination, may allow visualization of tumor cells for diagnosis. This is the most risk-free and inexpensive tissue diagnostic procedure, but its value is limited since tumor cells will not always be present in sputum even if a cancer is present. Also, noncancerous cells may occasionally undergo changes in reaction to inflammation or injury that makes them look like cancer cells.
bronchoscopy
BRONCHOSCOPY
  • Examination of the airways by bronchoscopy (visualizing the airways through a thin probe inserted in a tube through the nose or mouth) may reveal areas of tumor that can be sampled for pathologic diagnosis. A tumor in the central areas of the lung or arising from the larger airways is accessible to sampling using this technique.
slide55
Bronchoscopy may be performed using a rigid or a flexible, fiber-optic bronchoscope and can be performed in a same-day outpatient bronchoscopy suite, an operating room, or on a hospital ward. The procedure can be uncomfortable and require sedation or anesthesia. While the procedure is relatively safe
slide56
When a tumor is visualized and adequately sampled, an accurate cancer diagnosis is generally possible. Some patients may cough up dark-brown blood for one to two days after the procedure. More serious, and rare, complications include a greater amount of bleeding, decreased levels of oxygen in the blood, and heart arrythmias as well as complications from sedative medications and anesthesia.
slide57
Needle biopsy - Fine needle aspiration (FNA) through the skin, most commonly performed with radiological imaging for guidance, may be useful in retrieving cells for diagnosis from tumor nodules in the lungs. Needle biopsies are particularly useful when the lung tumor is peripherally located in the lung and not accessible to sampling by bronchoscopy.
slide58
This procedure is generally accurate when the tissue from the affected area is adequately sampled, but in some cases, adjacent or uninvolved areas of the lung may be mistakenly sampled. A small risk (3-5%) of an air leak from the lungs (called a pneumothorax, which can easily be treated) accompanies the procedure.
slide59
Thoracentesis - Sometimes lung cancers involve the lining tissue of the lungs (pleura) and lead to an accumulation of fluid in the space between the lungs and chest wall (called a pleural effusion).
slide60
Major surgical procedures - If none of the aforementioned methods yields a diagnosis, surgical methods must be employed to obtain tumor tissue for diagnosis. These can include mediastinoscopy (examining the chest cavity between the lungs through a surgically-inserted probe with biopsy of tumor masses or lymph nodes)
slide61
or thoracotomy (surgical opening of the chest wall with removal of as much tumor as possible). Thoracotomy is rarely able to completely remove a lung cancer, and both mediastinoscopy and thoracotomy carry the risks of major surgical procedures (complications such as bleeding, infection, risks from anesthesia and medications).
slide62
Blood tests – While routine blood tests alone cannot diagnose lung cancer, they may reveal biochemical or metabolic abnormalities in the body that accompany cancer. For example, elevated levels of calcium or of the enzyme alkaline phosphatase may accompany cancer that is metastatic to the bones
slide63
Doctors may use several tests to accurately stage a lung cancer, including laboratory (blood chemistry) tests, x-rays, CT scans, bone scans, and MRI scans. Abnormal blood chemistry tests may signal the presence of metastases in bone or liver, and radiological procedures can document the size of a tumor as well as possible spread to other organs.
slide64
NSCLC are assigned a stage from I to IV in order of severity.
  • In stage I, the cancer is confined to the lung.
  • In stages II and III, the cancer is confined to the chest (with larger and more invasive tumors classified as stage III).
  • Stage IV cancer has spread away from the chest to other parts of the body.
slide65
SCLC are staged using a two-tiered system:
  • Limited stage (LS) SCLC refers to cancer that is confined to its area of origin in the chest
  • In extensive-stage (ES) SCLC, the cancer has spread beyond the chest to other parts of the body.
slide66
How is lung cancer treated? Treatment for lung cancer can involve surgical removal of tumor, chemotherapy, or radiation therapy, as well as combinations of these methods. The decision about which treatments will be appropriate for a given individual must take into account the localization and extent of the tumor as well as the overall health status of the patient
slide67
As with other cancers, therapy may be prescribed that is intended to be curative (removal or eradication of a cancer) or palliative (measures that are unable to cure a cancer but can reduce pain and suffering). More than one type of therapy may be prescribed. In such cases, the therapy that is added to enhance the effects of the primary therapy is referred to as adjuvant therapy. An example of adjuvant therapy is chemotherapy or radiotherapy administered after surgical removal of a tumor in order to be certain that all tumor cells are killed.
slide68
Surgery - Surgical removal of the tumor is generally performed for limited-stage (Stage I or sometimes Stage II) NSCLC and is the treatment of choice for cancer that has not spread beyond the lung. About 10-35% of lung cancers can be removed surgically, but removal does not always result in a cure, since the tumors may already have spread and can recur at a later time. Among people who have an isolated, slow-growing lung cancer removed, 25 to 40% are alive 5 years after diagnosis.
slide69
Surgery may not be possible if the cancer is too close to the trachea or if the person has other serious conditions (such as severe heart or lung disease) that would limit their ability to tolerate an operation. Surgery is less often performed with SCLC because these tumors are less likely to be localized to one area that can be removed.
slide70
The surgical procedure chosen depends upon the size and location of the tumor. Surgeons must open the chest wall and may perform a wedge resection of the lung (removal of a portion of one lobe), a lobectomy (removal of one lobe), or a pneumonectomy (removal of an entire lung). Sometimes lymph nodes in the region of the lungs are also removed (lymphadenectomy).
slide71
Surgery for lung cancer is a major surgical procedure that requires general anesthesia, hospitalization and follow-up care for weeks to months. Following the surgical procedure, patients may experience difficulty breathing, shortness of breath, pain, and weakness. The risks of surgery include complications due to bleeding, infection, and complications of general anesthesia.
slide72
Radiation - Radiation therapy may be employed as a treatment for both NSCLC and SCLC. Radiation therapy uses high-energy x-rays or other types of radiation to kill dividing cancer cells. Radiation therapy may be given as curative therapy, palliative therapy (using lower doses of radiation than with curative regimens) or as adjuvant therapy to surgery or chemotherapy.
slide73
The radiation is either delivered externally, by using a machine that directs radiation toward the cancer, or internally through placement of radioactive substances in sealed containers within the area of the body where the tumor is localized.
slide74
Radiation therapy can be given if a person refuses surgery, if a tumor has spread to areas such as the lymph nodes or trachea making surgical removal impossible, or if a person has other conditions that make them too ill to undergo major surgery. Radiation therapy generally only shrinks a tumor or limits its growth when given as a sole therapy, yet in 10-15% of persons it leads to long-term remission and palliation of the cancer. Combining radiation therapy with chemotherapy can further increase the chances of survival when chemotherapy is administered.
slide75
External radiation therapy can generally be carried out on an outpatient basis while internal radiation therapy requires a brief hospitalization. A person who has severe lung disease in addition to a lung cancer may not be able to receive radiotherapy to the lung.
slide76
For external radiation therapy, a process called simulation is necessary prior to treatment. Using CT scans, computers, and precise measurements, simulation maps out the exact location where the radiation will be delivered, called the treatment field or port. This process usually takes 30 minutes to two hours. The external radiation treatment itself generally is done over four or five days a week for several weeks.
slide77
Radiation therapy does not carry the risks of major surgery, but it can have unpleasant side effects including tiredness and lack of energy. A reduced white cell count (rendering a person more susceptible to infection)
slide78
Chemotherapy - Both NSCLC and SCLC may be treated with chemotherapy. Chemotherapy refers to the administration of drugs that stop the growth of cancer cells by killing them or preventing them from dividing.
slide79
Chemotherapy may be given alone, as an adjuvant to surgical therapy, or in combination with radiotherapy. While a number of chemotherapeutic drugs have been developed, the platinum-based drugs have been the most effective in treatment of lung cancers.
slide80
Chemotherapy is the treatment of choice for most SCLC, since these tumors are generally widespread in the body when they are diagnosed. Only half of people who have SCLC survive for four months without chemotherapy.
slide81
With chemotherapy, their survival time is increased up to four- to fivefold. Chemotherapy alone is not particularly effective in treating NSCLC, but when NSCLC have metastasized; it can prolong survival in many cases.
slide82
Chemotherapy may be given as pills, as an intravenous infusion, or as a combination of the two. Chemotherapy treatments are usually given in an outpatient setting. A combination of drugs is given in a series of treatments, called cycles, over a period of weeks to months, with breaks in between cycles.
slide83
Unfortunately, the drugs used in chemotherapy also kill normally-dividing cells in the body, resulting in unpleasant side effects.
slide84
Damage to blood cells can result in increased susceptibility to infections and difficulties with blood clotting (bleeding or bruising easily). Other side effects include fatigue, weight loss, hair loss, nausea, vomiting, diarrhea, and mouth sores.
slide85
The side effects of chemotherapy vary according to the dosage and combination of drugs used and may also vary from individual to individual. Medications have been developed that can treat or prevent many of the side effects of chemotherapy. The side effects generally disappear during the recovery phase of the treatment or after its completion.
slide86
Brain prophylactic radiation – SCLC often spreads to the brain. Sometimes people with SCLC that is responding well to treatment are treated with radiation therapy to the head to treat very early spread to the brain (called
slide87
micrometastasis) that is not yet detectable with CT or MRI scans and has not yet produced symptoms. Brain radiation therapy can cause short-term memory problems, fatigue, nausea and other side effects.
slide88
Treatment of recurrence – Lung cancer that has returned following treatment with surgery, chemotherapy, and/or radiation therapy is called recurrent or relapsed. If a recurrent cancer is confined to one site in the lung, it may be treated with surgery. Relapsed tumors generally do not respond to the chemotherapeutic drugs that were previously administered.
slide89
Since platinum-based drugs are generally used in initial chemotherapy of lung cancers, these agents are not useful in most cases of recurrence.
slide90
A type of chemotherapy referred to as second-line chemotherapy is used to treat recurrent cancers that have previously been treated with chemotherapy, and a number of second-line chemotherapeutic regimens have been proved effective at prolonging survival.
slide91
What is the prognosis (outcome) of lung cancer? The prognosis of lung cancer refers to the chance for recovery and is dependent upon the localization and size of the tumor, the presence of symptoms, the type of lung cancer, and the overall health status of the patient.
slide92
SCLC has the most aggressive growth of all lung cancers, with a median survival time of only 2-4 months after diagnosis when untreated. (That is, by 2-4 months, half of all patients have died.) However, SCLC is also the type of lung cancer most responsive to radiation therapy and chemotherapy.
slide93
Because SCLC spreads rapidly and is usually disseminated at the time of diagnosis, methods such as surgical removal or localized radiation therapy are less effective in treating this tumor type. However, when chemotherapy is used alone or in combination with other methods, survival time can be prolonged four- to fivefold. Of all patients with SCLC, only 5-10% are alive 5 years after diagnosis. Most of those who survive have limited stage (LS) SCLC.
slide94
In non-small cell lung cancer (NSCLC), results of standard treatment are generally poor in all but the most localized cancers that can be surgically removed. However, in Stage I cancers that can be completely removed, the 5-year survival rate can approach 75%. Radiation therapy can produce a cure in a small minority of patients with NSCLC and relief of symptoms in most patients. In advanced-stage disease, chemotherapy offers modest improvements in survival time, although overall survival rates are poor.
slide95
Survival rates for lung cancer are generally lower than those for most cancers, with an overall 5-year survival rate for lung cancer of about 15% compared to 63% for colon cancer, 88% for breast cancer, and 99% for prostate cancer
slide96
How can lung cancer be prevented? Smoking cessation is the most important measure that can prevent lung cancer. Many products, such as nicotine gum, nicotine sprays, or nicotine inhalers, may be helpful to people trying to quit smoking. Minimizing exposure to passive smoking is also an effective preventive measure
slide97
Using a home radon test kit can identify and allow correction of increased radon levels in the home, which can also cause lung cancers. Methods that allow early detection of cancers, such as the helical low-dose CT scan, may also be of value in the identification of small cancers that can be cured by surgical resection and prevention of widespread , incurable metastatic cancer.
slide98
Familial predisposition While the majority of lung cancers are associated with tobacco smoking, the fact that not all smokers eventually develop lung cancer suggests that other factors, such as individual genetic susceptibility, may play a role in the causation of lung cancer. Numerous studies have shown that lung cancer is more likely to occur in both smoking and non-smoking relatives of those who have had lung cancer than in the general population.
slide99
Recent research has localized a region on the long (q) arm of the human chromosome number 6 that is likely to contain a gene that confers an increased susceptibility to the development of lung cancer in smokers.
slide100
Lung diseases The presence of certain diseases of the lung, notably chronic obstructive pulmonary disease (COPD), is associated with a slightly increased risk (four to six times the risk of a nonsmoker) for the development of lung cancer even after the effects of concomitant cigarette smoking are excluded.
slide101
Air pollution Air pollution, from vehicles, industry, and power plants, can raise the likelihood of developing lung cancer in exposed individuals. Up to 1% of lung cancer deaths are attributable to breathing polluted air, and experts believe that prolonged exposure to highly polluted air can carry a risk similar to that of passive smoking for the development of lung cancer.
slide102
What are the types of lung cancer? Lung cancers, also known as bronchogenic carcinomas ("carcinoma" is another term for cancer), are broadly classified into two types: small cell lung cancers (SCLC) and non-small cell lung cancers (NSCLC). This classification is based upon the microscopic appearance of the tumor cells themselves. These two types of cancers grow and spread in different ways, so a distinction between these two types is important.
slide103
SCLC comprise about 20% of lung cancers and are the most aggressive and rapidly growing of all lung cancers. SCLC are strongly related to cigarette smoking with only 1% of these tumors occurring in non-smokers. SCLC metastasize rapidly to many sites within the body and are most often discovered after they have spread extensively. Referring to a specific cell type often seen in SCLC, these cancers are sometimes called oat cell carcinomas.
slide104
NSCLCare the most common lung cancers, accounting for about 80% of all lung cancers. NSCLC has three main types that are named based upon the type of cells found in the tumor. They are:
slide105
Adenocarcinomas are the most commonly seen type of NSCLC in the U.S. and comprise up to 50% of NSCLC . While adenocarcinomas are associated with smoking like other lung cancers, this type is especially observed as well in non-smokers who develop lung cancer. Most adenocarcinomas arise in the outer, or peripheral, areas of the lungs. Bronchioloalveolar carcinoma is a subtype of adenocarcinoma that frequently develops at multiple sites in the lungs and spreads along the preexisting alveolar walls.
slide106
Squamous cell carcinomaswere formerly more common than adenocarcinomas; at present they account for about 30% of NSCLC. Also known as epidermoid carcinomas, squamous cell cancers arise most frequently in the central chest area in the bronchi.
  • Large cell carcinomas, sometimes referred to as undifferentiated carcinomas, are the least common type of NSCLC.
  • Mixtures of different types of NSCLC are also seen.
slide107
Other types of cancers can arise in the lung; these types are much less common than NSCLC and SCLC and together comprise only 5-10% of lung cancers:
  • Bronchial carcinoids account for up to 5% of lung cancers. These tumors are generally small (3-4 cm or less) when diagnosed and occur most commonly in persons under 40 years of age. Unrelated to cigarette smoking, carcinoid tumors can metastasize, and a small proportion of these tumors secrete hormone-like substances.
slide108
Carcinoids generally grow and spread more slowly than bronchogenic cancers, and many are detected early enough to be amenable to surgical resection.
  • Cancers of supporting lung tissue such as smooth muscle, blood vessels, or cells involved in the immune response can rarely occur in the lung
slide111
What is staging of lung cancer?The stage of a tumor refers to the extent to which a cancer has spread in the body. Staging involves both evaluation of a tumor’s size as well as the presence or absence of metastases in the lymph nodes or in other organs. Staging is important for determining how a particular tumor should be treated,
slide112
since lung cancer therapies are geared toward specific tumor stages. Staging of a tumor is also critical in estimating the prognosis of a given patient, with higher-stage tumors generally having a worse prognosis than lower-stage tumors.
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Lung cancer is the most common cause of cancer deaths in men and women. Prognosis depends on the extent of disease at thooe time of diagnosis. Accurate staging, assessing the extent of local and distant disease, is necessary to determine resectability and overall prognosis. Surgical resection is the only curative hope for patientswith lung cancer.
slide114
One goal of staging is to classify properly operable patients and avoid surgery in those with unresectable disease.
slide115
If the diagnosis is lung cancer, the doctor will want to learn the stage (or extent) of the disease. Lung cancer staging is done to find out whether the cancer has spread and, if so, to what parts of the body. Lung cancer often spreads to the brain or bones. Knowing the lung cancer stage of the disease helps the doctor plan treatment. Some tests used to determine the lung cancer stage and whether the cancer has spread include:
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CAT (CT) scan (computed tomography). A computer linked to an x-ray machine creates a series of detailed pictures of areas inside the body.
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MRI (magnetic resonance imaging). A powerful magnet linked to a computer makes detailed pictures of areas inside the body.
  • Radionuclide scanning. Scanning can show whether cancer has spread to other organs, such as the liver. The patient swallows or receives an injection of a mildly radioactive substance. A machine (scanner) measures and records the level of radioactivity in certain organs to reveal abnormal areas.
slide118
Bone Scan. A bone scan, one type of radionuclide scanning, can show whether cancer has spread to the bones. A small amount of radioactive substance is injected into a vein. It travels through the bloodstream and collects in areas of abnormal bone growth. An instrument called a scanner measures the radioactivity levels in these areas and records them on x-ray film.
slide119
Mediastinoscopy/Mediastinotomy. A mediastinoscopy can help show whether the cancer has spread to the lymph nodes in the chest. Using a lighted viewing instrument, called a scope, the doctor examines the center of the chest (mediastinum) and nearby lymph nodes. In mediastinoscopy, the scope is inserted through a small incision in the neck; in mediastinotomy, the incision is made in the chest. In either procedure, the scope is also used to remove a tissue sample. The patient receives a general anesthetic.
slide124
The TNM (tumor, node, metastasis) system is commonly used to classify the anatomic extent of disease, the currently accepted staging system for non-small cell bronchogenic carcinoma. Current statistics on 5 year survival are also considered.
slide127
Primary Tumor (T)
  • ClinPath DEFINITIONS□□TXPrimary tumor cannot be assessed, or tumor proven by presence of malignant cells in sputum or bronchial washings but not visualized by imaging or bronchoscopy□□
slide128
T0No evidence of primary tumor
  • □□TisCarcinoma in situ
  • □□T1Tumor 3 cm or less in greatest dimension, surrounded by lung or visceral pleura, without bronchoscopic evidence of invasion more proximal than the lobar bronchus* (i.e., not in main bronchus)□□
slide129
T2Tumor with any of the following features or size or extent:More than 3 cm in greatest dimension Involves main bronchus, 2 cm or more distal to the carina Invades the visceral pleura Associated with atelectasis or obstructive pneumonitis that extends toThe hilar region but does not involve the entire lung□□
slide130
T3Tumor of any size that
  • directly invades any of the following: chest wall (including superior sulcus tumors), diaphragm, mediastinal pleura, parietal pericardium; or tumor in the main bronchus less than 2 cm distal to the carina but or without involvement of the carina; or associated atelectasis obstructive pneumonitis of the entire lung
slide131
T4Tumor of any size that invades any of the following: mediastinum, heart,great vessels, trachea, esophagus,vertebral body, carina; separate tumor nodule(s) in the same lobe; or tumor with a malignant pleural effusion*** The uncommon superficial tumor of any size with its invasive component
slide132
The uncommon superficial tumor of any size with its invasive component limited to the bronchial wall,
  • which may extend proximal to the main bronchus, is also classified T1.
slide133
Most pleural effusions associated with lung cancer are due to tumor. However, there are a few patients in whom multiple cytopathologic examinations of pleural fluid are negative for tumor. In these cases, fluid is nonbloody and is not an exudate.
slide136
Lymph Nodes
  • Mediastinal
  • Peritracheal (including those that may be designated tracheobronchial, e.g., lower peritracheal, including
  • azygos)
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Pretracheal and retrotracheal (including precarinal)
  • Aortic (including subaortic, aorticopulmonary window, and periaortic, incluiding ascending aorta or
  • phrenic)
  • Subcarinal
slide138
Periesophageal
  • Pulmonary ligament
  • Intrapulmonary
  • Hilar (proximal lobar)
  • Peribronchial
  • Intrapulmonary (including interlobar, lobar, segmental)
slide139
Regional Lymph Nodes (N)
  • ClinPath DEFINITIONS
  • □□NXRegional lymph nodes cannot be assessed
  • □□N0No regional lymph node metastasis
  • □□N1Metastasis to ipsilateral peribronchial and/or ipsilateral hilar lymph nodes and intrapulmonary nodes involved by direct extension of the primary tumor
slide140
□□N2Metastasis to ipsilateral mediastinal and/or subcarinal lymph node(s)
  • □□N3Metastasis in contralateral mediastinal, contralateral hilar, ipsilateral or contralateral scalene or supraclavicular lymph node(s) 
slide141
Distant Metastasis (M)
  • ClinPath DEFINITIONS□□MXDistant metastasis cannot be assessed□□M0No distant metastasis□□M1Distant metastasis present (includes synchronous separate nodule(s) in a different lobe) 
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Tumor size, level of lymph node involvement and extent of distant metastases (spread). Stages are identified in the following ways:
  • Stage 0 Lung Cancer. The cancer is limited to the lining of air passages and hasn't invaded lung tissue. The cancer can usually be eliminated when caught and treated
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Stage I Lung Cancer. The cancer has spread to layers of lung tissue but has not reached the lymph nodes or beyond. There is a 60 percent to 80 percent chance of surviving the disease 5 years when it's caught and treated at this stage.
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Stage II Lung Cancer. The cancer has invaded neighboring lymph nodes or spread to the chest wall. There is a 40 percent to 50 percent chance of surviving the disease 5 years when it's caught and treated at this stage.
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Stage IIIA Lung Cancer. The cancer has spread from the lung to lymph nodes beyond the lung area. Cancer usually isn't treated surgically at this stage. There is a 15 percent to 30 percent chance of surviving 5 years when the disease is caught and treated with radiation or chemotherapy at this point.
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Stage IV Lung Cancer. In Stage 4 lung cancer the cancer has spread to other parts of the body, such as the liver, bones or brain. There is less than a 2 percent chance of surviving the disease 5 years when it's treated at this stage.
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Stage Grouping
  • ClinPathDefinitions
  • □□OccultTXN0M0
  • □□0TisN0M0□□IAT1N0M0
  • □□IBT2N0M0□□IIAT1N1M0
  • □□IIBT2N1M0   T3N0M0
  • □□IIIAT1N2M0   T2N2M0   T3N1M0   T3N2M0
  • □□IIIBAny TN3M0   T4Any NM0
  • □□IVAny TAny NM1 
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Histopathologic Type
          • There are four common types of lung cancer
  • Squamous cell carcinoma (epidermoid carcinoma)
  • Variant: Spindle cell
  • Small cell carcinoma
  • Oat cell carcinoma
  • Intermediate cell type
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Combined oat cell carcinoma
  • Adenocarcinoma
  • Acinar adenocarcinoma
  • Papillary adenocarcinoma
  • Bronchiolo-alveolar carcinoma
  • Solid carcinoma with mucus formation
  • Large cell carcinoma
  • Variants: Giant cell carcinoma
  • Clear cell carcinoma
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This classification applies only to carcinomas, including small cell carcinoma
  • The clssification may be applied to those
  • “ undifferentiated carcinomas “. Sarcomas are not included because the extent and the prognosis has not been established or does not pertain.
surgical staging
SURGICAL STAGING
  • The role of invasive staging and the specific procedures utilized deserve mention. Distinction must be made between clinical stage and pathological stage. The former is based solely on non –invasive imaging, where as the latter depends on actual histologic material obtaine deither by invasive staging or at the time of the surgical resection.
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Invasive staging is reserved for cases in which definitive assessment of mediastinal lymph node involvement will affect management.Specifically whether to proceed with thoracotomy.
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preliminary working model from head and neck squamous cell carcinoma (HNSCC) has provided important clues into the genetic alterations that drive the neoplastic process in upper aerodigestive tract tumors
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Moreover, scientists have used these clonal genetic alterations to detect rare neoplastic cells in surgical margins of HNSCC patients and in the sputum of patients with lung cancer. This HNSCC model will now serve as a template to identify and characterize critical regions of chromosomal loss in non-small cell lung cancer and the development of a comprehensive molecular progression model for lung cancer
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They have already confirmed that critical genetic events in HNSCC, such as loss at chromosome 9p21 also occur in lung cancer and these will now be characterized for their occurrence and timing in lung cancer progression. Moreover, tumor suppressor genes from two important regions of loss will be evaluated for inactivation in primary lung cancers
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Early genetic events in lung cancer progression will be used to further develop novel diagnostic and staging strategies in the clinical setting. These novel approaches demonstrate the value of developing genetic progression models to augment translational projects based on emerging molecular knowledge.
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During the past 2½ years, They defined six specific genes, each of which has defined or potential involvement in lung tumorigenesis, for which expression is inactivated in lung cancers in association with aberrant hypermethylation of CpG islands in the promoter region of the gene.
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They are now timing these changes for key stages of early lung tumor progression and will use this information to evaluate the utility of the methylation events as markers for the clinical goals .
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In addition, it is determined that incremental increases in DNA methyltransferase activity (DNA-MTase), which is the enzyme responsible for catalyzing DNA methylation, accompany progression steps in lung and other tumor types. They will test the utility of visualizing the cell populations responsible for this change for providing new means to clinically assess the earliest stages of, and risk status for, lung cancer.